Work sampling: a quantitative analysis of nursing activity in a neuro-rehabilitation setting

Title.  Work sampling: a quantitative analysis of nursing activity in a neuro-rehabilitation setting.
Aim.  The aim of this investigation was to establish the distribution and proportion of nursing activity represented by patient-related care activities (direct and indirect), and other nursing activities (unit-related and personal) within one inpatient neurological rehabilitation unit.
Background.  A set of tools has been developed for estimating the care/nursing hours required for direct hands-on patient care in hospital rehabilitation settings. However, to apply this information to estimate the actual staffing requirements in relation to a given caseload, it is necessary to know the proportion of nursing workload assigned to other activities and how this may vary throughout the day.
Method.  A work sampling study was conducted during 2004. A snapshot of nursing activity was recorded at 5-minute intervals from 06·00 to 23·55 spread over 2 weeks, with one session from 06·00 to 15·25 and the second from 15·30 to 23·55.
Results.  A total of 8883 nursing activities were observed and recorded over 126 hours and categorized as follows: 4060 (46%) direct patient care, 2218 (25%) indirect patient care, 874 (10%) unit-related and 1731 (19%) personal time. The proportions of direct care fluctuated throughout the day, with direct care activities mainly concentrated in early mornings and to a lesser extent evenings.
Conclusion.  Direct patient care accounted for less than half of the nursing activity in a rehabilitation setting. Estimates of staffing requirement must also take account of the time required for indirect care and non-patient related activity.     

The use of conversational analysis: nurse–patient interaction in communication disability after stroke

Title.  The use of conversational analysis: nurse–patient interaction in communication disability after stroke.
Aim.  This paper is a report of a study to explore how nursing staff and patients with aphasia or dysarthria communicate with each other in natural interactions on a specialist stroke ward.
Background.  Nursing staff often talk with patients in a functional manner, using minimal social or affective communication. Little nursing research has been carried out with patients who have communication difficulties. Conversational analysis, used in other healthcare settings, is a way to explore these interactions in depth in order to gain further understanding of the communication process.
Method.  An observational study was carried out in 2005 and the data were 35·5 hours of videotape recording and field notes with 14 nursing staff and five patients with aphasia or dysarthria. The recordings were analysed using conversation analysis.
Findings.  Nursing staff controlled the conversations by controlling the topic and flow of conversations, creating asymmetry in all interactions. Patients had very little input because of taking short turns and responding to closed questions. These behaviours are related to the institutional context in which they occur.
Conclusion.  In rehabilitation, the focus for interaction may be thought to be patient goals, worries or plans for the future, but in this study nursing staff controlled the conversations around nursing tasks. This may be because they do not have the confidence to hold conversations with people with communication problems. Nursing staff need to receive training to reinforce communication rehabilitation programmes and to engage more fully with patients in their care, but also that a wider institutional culture of partnership is developed on stroke wards.     

Nursing students' knowledge and practice of infection control precautions: an educational intervention

Title.  Nursing students' knowledge and practice of infection control precautions: aneducational intervention.
Aim.  This paper is a report of the effectiveness of a purpose-designed education program in improving undergraduate nursing students' understanding and practice of infection control precautions.
Background.  The severe acute respiratory syndrome outbreak in 2003 highlighted that healthcare workers were under-prepared for such an epidemic. While many in-service education sessions were arranged by institutions in response to the outbreak, preservice nursing education has overlooked preparation for handling such infectious disease epidemics.
Method.  A quasi-experimental design was used and a 16-hour, purpose-designed infection control education programme was implemented for preservice nursing students in southern Taiwan. Self-administered questionnaires were distributed at three time points during the period September 2005 to April 2006 to examine the sustainability and effectiveness of the intervention.
Results.  A total of 175 preservice nursing students participated in the study. Following the education programme, students in the intervention group showed a statistically significant improvement across time in their knowledge of these precautions [ F _{(2, 180)} = 13·53, P  <   0·001] and confidence in resolving infection-related issues [ F _{(1·79, 168·95)} = 3·24] when compared with those in the control group.
Conclusion.  To improve nursing students' capacity in responding to infectious epidemics, an educational programme that integrates the theme of infection precautions, learning theory and teaching strategies is recommended for all nursing institutes.     

Acute care teaching in the undergraduate nursing curriculum

Aim:  To incorporate basic aspects of acute care into the undergraduate nursing programme by providing an opportunity for the development of knowledge and skills in the early recognition and assessment of deteriorating patients on general hospital wards.
Background:  Acute care initiatives implemented in the hospital setting to improve the identification and management of 'at risk' patients have focused on the provision of education for trained or qualified staff. However, to ensure student nurses are 'fit to practice' at the point of registration, it has been recommended that acute care theory and skills are incorporated into the undergraduate nursing curriculum.
Practice development initiative:  An 'Integrated Nursing Care' module was incorporated into year 3 of the undergraduate nursing programme to introduce students to acute care theory and practice. Module content focuses on the early detection and management of acute deterioration in patients with respiratory, cardiac, neurological or renal insufficiencies. We used a competency-based framework to ensure the application of theory to practice through the use of group seminars. High-fidelity patient-simulated clinical scenarios were a key feature. The United Kingdom Resuscitation Council Intermediate Life Support course is also an important component of the module.
Conclusions:  Incorporating the Integrated Nursing Care module into the undergraduate nursing curriculum provides pre-registration students the opportunity to develop their knowledge and skills in acute care.
Relevance to clinical practice:  The provision of undergraduate education in care of the acutely ill patient in hospital is essential to improve nurses' competence and confidence in assessing and managing deteriorating patients in general wards at the point of registration.     

A comparative study of nursing staff, care recipients' and their relatives' perceptions of quality of older people care

hasson h. & arnetz j.e. (2009)   A comparative study of nursing staff, care recipients' and their relatives' perceptions of quality of older people care. International Journal of Older People Nursing   5 , 5–15
doi: 10.1111/j.1748-3743.2009.00186.x
Background.  Comparisons of different stakeholders' ratings of the quality of older people care can help to drive quality improvement.
Aim.  The aim was to compare staff, older care recipients' and their relatives' quality of care ratings.
Design.  Cross-sectional questionnaire surveys in 2003 and 2004, using a repeated measures design on an organizational level.
Methods.  Nursing staff, care recipients and relatives in two older people care organizations were included. The ratings of an overall quality grade, information, activities, general care and staff skills were compared between the respondent groups.
Results.  Care recipients in both organizations rated the overall quality grade significantly higher than nursing staff and relatives. Staff ratings of the information given to care recipients were significantly more positive than care recipients' and relatives' ratings. All three groups gave lowest ratings to the quality of activities offered to care recipients, with lowest ratings from nursing staff.
Conclusions.  Concurrent measurements of staff, care recipients and relatives' care quality perceptions can provide a broad evaluation of an organization's strength and limitations.
Relevance to clinical practice.  Staff, care recipients' and relatives' perceptions can be useful for older people care organizations and decision makers in developing care processes and outcomes of care.     

Characterizing violence in health care in British Columbia

Title.  Characterizing violence in health care in British Columbia.
Background.  The high rate of violence in the healthcare sector supports the need for greater surveillance efforts.
Aim.  The purpose of this study was to use a province-wide workplace incident reporting system to calculate rates and identify risk factors for violence in the British Columbia healthcare industry by occupational groups, including nursing.
Methods.  Data were extracted for a 1-year period (2004–2005) from the Workplace Health Indicator Tracking and Evaluation database for all employee reports of violence incidents for four of the six British Columbia health authorities. Risk factors for violence were identified through comparisons of incident rates (number of incidents/100,000 worked hours) by work characteristics, including nursing occupations and work units, and by regression models adjusted for demographic factors.
Results.  Across health authorities, three groups at particularly high risk for violence were identified: very small healthcare facilities [rate ratios (RR) = 6·58, 95% CI =3·49, 12·41], the care aide occupation (RR = 10·05, 95% CI = 6·72, 15·05), and paediatric departments in acute care hospitals (RR = 2·22, 95% CI = 1·05, 4·67).
Conclusions.  The three high-risk groups warrant targeted prevention or intervention efforts be implemented. The identification of high-risk groups supports the importance of a province-wide surveillance system for public health planning.     

What do nurses do? An observational survey of the activities of nurses on acute surgical and rehabilitation wards

Aim  The subject of the study described in this article is an activity analysis of nursing care given on an acute surgical ward at a District General Hospital as compared to that given on a rehabilitation ward at a Community Hospital.
Methods  Obtaining a global overview of nursing activities on the two study wards was a focal issue. The project consisted of undertaking in excess of 60 h of observation with 10 registered nurses (RNs) of various grades in the two settings.
Findings It was found that both sets of nurses undertook similar types of activities. Overall more indirect care activities than direct care occurred on both wards. These findings are similar to the findings of other studies where the majority of RNs' activities are said to relate to the co-ordinating and management aspects of patient care.
Conclusion  It is concluded that the 'glue function' or maintaining a holistic overview of patient care given by all members of the health care team is an important part of nursing care delivery.     

Determining nurse staffing needs: the workload intensity measurement system

hoi s.y., ismail n., ong l.c. & kang j. (2010) Journal of Nursing Management 18 , 44–53 Determining nurse staffing needs: the workload intensity measurement system
Objective  To develop a prototype nursing workload intensity measurement system (WIMS).
Background  Current nurse staffing was determined based on a development. The predetermined nurse-to-patient ratio of a measurement system in the present work environment was deemed essential.
Methods  The study was conducted in a 1500-bed acute care hospital in Singapore. A questionnaire was designed to identify critical indicators for workload measurement. Nineteen wards were observed over a period of 1 week on day shifts. The WIMS was developed using regression modelling.
Results  Nursing time required for a low-acuity ward increased from 90.5 to 177.1 hours per day. The WIMS was developed using nursing diagnoses as critical indicators of workload. The model (WIMS) yield R ² values ranging from 0.615 to 0.736 across the six key disciplines, rendering it a model with relatively good predictive ability of nursing time required.
Conclusion  In such a rapidly changing work environment, workload measurement systems should be reviewed periodically. The WIMS was developed as a potential methodology for measuring staffing needs.
Implication for Nursing Management  Workload predictions should de-link patient dependency with acuity status as both do not correlate, as evidenced by this study.     

Case Study: The Challenges of Self-Management of Exacerbation of Pulmonary Symptoms

PURPOSE.  This case study demonstrates the signs and symptoms of pulmonary exacerbation and the challenges of self-management for a female veteran.
DATA SOURCES.  Data were obtained through the author's clinical practice in primary care nursing and research literature sources.
DATA SYNTHESIS.  The appropriate nursing diagnosis, nursing interventions, and patient outcomes were identified through the use of NANDA-International, the Nursing Interventions Classification, and the Nursing Outcomes Classification.
CONCLUSIONS.  This case study illustrates the appropriate nursing diagnosis, interventions, and outcomes pertinent to an individual with pulmonary exacerbations. It provides a framework for nurses in primary care when caring for individuals with pulmonary exacerbations.
IMPLICATIONS FOR NURSING PRACTICE.  Employing the NANDA-International standardized nursing diagnoses, the Nursing Interventions Classification and the Nursing Outcomes Classification provided the needed constructs for improving care for a patient that had pulmonary issues in a primary care setting.     

Standardized antibacterial honey (Medihoney™) with standard therapy in wound care: randomized clinical trial

Title.  Standardized antibacterial honey (Medihoney™) with standard therapy in wound care: randomized clinical trial.
Aim.  This paper is a report of a study to compare a medical grade honey with conventional treatments on the healing rates of wounds healing by secondary intention.
Background.  There is an increasing body of evidence to support the use of honey to treat wounds, but there is a lack of robust randomized trials on which clinicians can base their clinical judgement.
Method.  A sample of 105 patients were involved in a single centre, open-label randomized controlled trial in which patients received either a conventional wound dressing or honey. Data were collected between September 2004 and May 2007.
Results.  The median time to healing in the honey group was 100 days compared with 140 days in the control group. The healing rate at 12 weeks was equal to 46·2% in the honey group compared with 34·0% in the conventional group, and the difference in the healing rates (95% confidence interval, CI) at 12 weeks between the two groups was 12·2% (−13·6%, 37·9%). The unadjusted hazard ratio (95% CI) from a Cox regression was equal to 1·30 (0·77, 2·19), P  = 0·321. When the treatment effect was adjusted for confounding factors (sex, wound type, age and wound area at start of treatment), the hazard ratio increased to 1·51 but was again not statistically significant.
Conclusion.  Wound area at start of treatment and sex are both highly statistically significant predictors of time to healing. These results support the proposition that there are clinical benefits from using honey in wound care, but further research is needed.     

Determining Critical Incident Nursing Interventions for the Critical Care Setting: A Pilot Study

PURPOSE.  The purpose of this research survey was to determine which Adult Critical Care Core Nursing Interventions (ACCCNIs) in the Nursing Interventions Classification constitutes a critical incident nursing intervention (CINI). A CINI is defined as any indirect or direct care registered nurse (RN)-initiated treatment performed in response to a life-threatening nursing diagnosis.
METHODS.  A list of ACCCNIs were sent to 50 critical care RNs in two survey rounds. Responses >80% for each ACCCNI was determined to be a CINI.
FINDINGS.  Forty-one ACCCNIs were determined to be CINIs.
CONCLUSIONS.  It is recommended that CINIs be included as a separate Nursing Intervention Classification category to reflect current nursing practice.
IMPLICATIONS FOR NURSING PRACTICE.  CINIs can enhance RN competency, education, and vigilance, thereby preventing or decreasing the number of deaths that occur from critical incidents.     

Nurses' everyday activities in hospital care

Aim  This study aims at examining nurses' work in somatic and psychiatric wards in a hospital in Sweden.
Background  It is asked whether the humanistic ideology, emphasizing holistic care and human interaction more than practical skills, which has become widespread in the Swedish nursing education programmes, fits with the actual work that nurses carry out.
Method  In this study, diaries on work activities were written during 5 days by 30 nurses.
Results  It turned out that the nurses generally spend 38% of their working time with patients (nursing) and the remaining time on other activities.
Discussion  There are certain differences between clinics and they can to some extent be explained by differences in work organization.
Conclusion  The results in this piece of research indicate that a relatively small proportion of nurses' working time is used for general and specific nursing. It should be asked whether or to what extent the humanistic and holistic perspective taught in nursing education will be utilized in practical nursing.     

Nurse staffing and patient outcomes in Belgian acute hospitals: cross-sectional analysis of administrative data

Background

Studies have linked nurse staffing levels (number and skill mix) to several nurse-sensitive patient outcomes. However, evidence from European countries has been limited.

Objectives

This study examines the association between nurse staffing levels (i.e. acuity-adjusted Nursing Hours per Patient Day, the proportion of registered nurses with a Bachelor's degree) and 10 different patient outcomes potentially sensitive to nursing care.

Design-setting-participants

Cross-sectional analyses of linked data from the Belgian Nursing Minimum Dataset (general acute care and intensive care nursing units: n = 1403) and Belgian Hospital Discharge Dataset (general, orthopedic and vascular surgery patients: n = 260,923) of the year 2003 from all acute hospitals (n = 115).

Methods

Logistic regression analyses, estimated by using a Generalized Estimation Equation Model, were used to study the association between nurse staffing and patient outcomes.

Results

The mean acuity-adjusted Nursing Hours per Patient Day in Belgian hospitals was 2.62 (S.D. = 0.29). The variability in patient outcome rates between hospitals is considerable. The inter-quartile ranges for the 10 patient outcomes go from 0.35 for Deep Venous Thrombosis to 3.77 for failure-to-rescue. No significant association was found between the acuity-adjusted Nursing Hours per Patient Day, proportion of registered nurses with a Bachelor's degree and the selected patient outcomes.

Conclusion

The absence of associations between hospital-level nurse staffing measures and patient outcomes should not be inferred as implying that nurse staffing does not have an impact on patient outcomes in Belgian hospitals. To better understand the dynamics of the nurse staffing and patient outcomes relationship in acute hospitals, further analyses (i.e. nursing unit level analyses) of these and other outcomes are recommended, in addition to inclusion of other study variables, including data about nursing practice environments in hospitals.     

Measuring the intensity of nursing care: making use of the Belgian Nursing Minimum Data Set

BACKGROUND: The Belgian Nursing Minimum Data Set (B-NMDS) is a nationwide registration of 23 nursing activities. It was developed for the measurement of nursing care in acute hospitals. It is used to support healthcare management & policy decision making such as hospital financing and nurse staffing decisions. OBJECTIVE: To develop a measure of the intensity of nursing care based on information that is available in the B-NMDS. DESIGN-SETTING-PARTICIPANTS: Retrospective analysis of the B-NMDS from all Belgian acute hospitals (n=115) for the year 2003. The sample included 690,258 inpatient days for 298,691 patients that were recorded from 1637 acute care nursing units. METHODS: The 23 nursing activities were synthesized into one new latent variable by PRINQUAL analysis. This variable was evaluated as a measure of nursing care intensity using key characteristics of the San Joaquin patient classification system, which was designed to measure the intensity of nursing care. RESULTS: The main NMDS component from the PRINQUAL analysis accounted for 26.8% of the variance. The distribution of inpatient days over all four San Joaquin categories is: 11.1% (self-care); 40.4% (average care); 30.8% (above average care); 17.7% (intensive care). In 97.5% of the nursing units the intensity of nursing care score of the B-NMDS (main NMDS component) followed the ordinality of the San Joaquin classification system. Furthermore, the San Joaquin categories alone explained more variability--70.2% in the intensity of nursing care measure (main NMDS component) than did other determinants, such as department type, age, diagnostic-related groups (DRG) and severity of illness, hospital type and hospital size together. CONCLUSION: The B-NMDS is an instrument that produces a measure of the intensity of nursing care in acute hospitals.     

Psycho-social factors affecting elders' maltreatment in long-term care facilities

Natan M.B., Lowenstein A. & Eisikovits Z. (2010) Psycho-social Factors Affecting Elders' Maltreatment in Long-term Care Facilities. International Nursing Review 57 , 113–120
Aim:  To examine and analyse major variables affecting maltreatment of elderly nursing home residents. The study was based on two theoretical paradigms: the theoretical model for predicting causes of maltreatment of elderly residents developed by Pillemer, and the Theory of Reasoned Action developed by Ajzen & Fishbein.
Methods:  The study employed a correlational quantitative method. The research population consisted of the staff of 22 nursing homes in Israel. Six hundred questionnaires were distributed in these facilities and 510 were completed and returned (85%). In addition, 24 questionnaires were distributed among directors of the facilities and 22 were returned (91.6%).
Findings:  Slightly more than half of the staff sampled reported abuse of elderly residents over the past year, as manifested in one or more of types of maltreatment. The total number of various types of maltreatment reported was 513. About two-thirds of the cases were incidents of neglect. Seventy per cent of respondents reported that they had been present at incidents in which another staff member abused an elderly resident in one or more types of maltreatment, and in such situations mental abuse and mental neglect were the most prevalent forms of maltreatment.
Conclusion and Recommendations:  This is the first study to examine elder maltreatment in the long-term care population of Israel. The research findings produce an expanded and improved research model investigating elder maltreatment in long-term nursing homes.     

Alarm limit settings for early warning systems to identify at-risk patients

Title.  Alarm limit settings for early warning systems to identify at-risk patients.
Aim.  This paper is a report of a study conducted to provide objective data to assist with setting alarm limits for early warning systems.
Background.  Early warning systems are used to provide timely detection of patient deterioration outside of critical care areas, but with little data from the general ward population to guide alarm limit settings. Monitoring systems used in critical care areas are known for excellent sensitivity in detecting signs of deterioration, but give high false positive alarm rates, which are managed with nurses caring for two or fewer patients. On general wards, nurses caring for four or more patients will be unable to manage a high number of false alarms. Physiological data from a general ward population would help to guide alarm limit settings.
Methods.  A dataset of continuous heart rate and respiratory rate data from a general ward population, previously collected from July 2003–January 2006, was analyzed for adult patients with no severe adverse events. Dataset modeling was constructed to analyze alarm frequency at varying heart rate and respiratory rate alarm limits.
Results.  A total of 317 patients satisfied the inclusion criteria, with 780·71 days of total monitoring. Sample alarm settings appeared to optimize false positive alarm rates for the following settings: heart rate high 130–135, low 40–45; respiratory rate high 30–35, low 7–8. Rates for each selected limit can be added to calculate the total alarm frequency, which can be used to judge the impact on nurse workflow.
Conclusion.  Alarm frequency data will assist with evidence-based configuration of alarm limits for early warning systems.     

Use of NIDSEC-compliant CIS in community-based nursing-directed prenatal care to determine support of Nursing Minimum Data Set objectives

If the Nursing Minimum Data Set elements, specifically the nursing care elements, are included in a clinical information system, nursing will be able to measure outcomes and contributions to both healthcare and nursing to build knowledge using clinical data. The purpose of the reported study was to determine whether a Nursing Information and Data Set Evaluation Center-compliant clinical information system using the Omaha System could support the Nursing Minimum Data Set goal to describe nursing care in a community health setting. The secondary data set analysis was conducted. The findings showed that although the clinical information system was compliant with the standard, used a recognized American Nurses Association nursing vocabulary, and supported the collection of the Nursing Minimum Data Set, the data were not sufficient to address the purposes of the Nursing Minimum Data Set. The implications for nursing research and clinical practice are outlined.